Federal Reports

The COVID-19 pandemic accelerated efforts by the Veterans Health Administration (VHA) to expand veteran access to telehealth. Accordingly, VHA’s Connected Care Office created a new digital divide consult to issue iPhones to veterans experiencing homelessness who were enrolled in the Department of Housing and Urban Development VA Supportive Housing (HUD-VASH) Program. VHA was already loaning iPads to other veterans who lacked telehealth capable devices through the digital divide consult process. The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of iPads and iPhones for veterans met mission needs while minimizing waste during fiscal year (FY) 2020 and through the first two quarters of FY 2021.In July 2020, Connect Care officials purchased 10,000 iPhones with unlimited prepaid data plans for the homeless veterans enrolled in the HUD-VASH program. However, 8,544 of the 10,000 iPhones remained in storage as of July 2021, as demand for the iPhones was much lower than anticipated. The OIG found that this resulted in an estimated $1.8 million in wasted data plan costs. The OIG also identified opportunities for improvement regarding data plans for nearly 81,000 iPads purchased. Because Connected Care did not have strong enough oversight procedures for reducing or eliminating data plan waste, it incurred approximately $571,000 in additional wasted data plan costs.The OIG made two recommendations to the under secretary for health. The first was to establish a realistic goal for days in storage and a process for monitoring days in storage. The second was to determine the viability of initiating data plan charges only when a device is issued to the veteran.

The VA Office of Inspector General (OIG) evaluated allegations that Portland VA Medical Center (facility) staff “inappropriately discharged” a patient with “severe cognitive impairment,” then “turned away” the patient, and failed to provide the patient’s records to Adult Protective Services (APS). The OIG identified a concern regarding discharge coordination with family.In 2021, the patient, with a history of alcohol use and cognitive impairment, presented to the facility’s Emergency Department with gangrene and homelessness. Throughout the patient’s 33-day admission, staff evaluated the patient’s cognitive functioning, communicated with the patient’s family and APS staff, and pursued placements.Approximately an hour after discharge, the patient presented to the facility’s Emergency Department. A social worker provided the patient with a bus ticket “to return to the shelter.” Within an hour, the patient returned and the social worker reprinted the instructions and advised the patient to board the bus.The OIG substantiated that the patient was discharged to a non-VA homeless shelter by cab but did not substantiate the patient was “inappropriately discharged.” Staff determined that direct transport was preferable to the more complicated bus route.The OIG was unable to determine whether staff discussed the patient’s final discharge plan with family due to an absence of documentation and conflicting reports.The OIG substantiated that staff did not establish a safe transportation plan after the patient returned to the Emergency Department after discharge.The OIG did not substantiate that staff failed to provide the patient’s records to APS. However, staff returned requests without providing information regarding specific missing elements.The OIG made three recommendations related to consideration of requiring staff to document family contacts, a review of the Emergency Department social worker’s care coordination of the patient, and consideration of Privacy Office staff communicating the missing element(s) when returning a release of information request.

Our office, through a partnership with the Pandemic Response Accountability Committee, obtained data from the United States Small Business Administration (SBA) related to their Economic Injury Disaster Loans (EIDL) and Paycheck Protection Program (PPP) loans. We scheduled this audit after identifying potential matches between the SBA data and TVA employees. Our audit objective was to determine if TVA’s policies and procedures are effective in assuring outside employment of TVA employees is properly approved. Our audit scope was limited to TVA employees identified as having potential outside employment or business ownership through review of EIDL and PPP loan data received from the SBA. We found TVA’s policies and procedures are not effective in assuring outside employment of TVA employees is properly approved. Specifically, we found TVA employees are not consistently submitting their outside employment or business ownership on TVA Form 15570 prior to accepting outside employment or opening a business. In addition, we found TVA’s (1) review for potential conflicts of interest and (2) application of 5 CFR § 7901 requirements could be improved. We also found (1) the TVA Forms 15570 on file were not updated as required and (2) roles and responsibilities in the outside employment approval process could be clarified.

As of March 31, 2022, there are 71 open recommendations, 7 of which were reported as implemented by management but remain open per third-party (CLA/other Independent Public Accounting firm (IPA)/OIG) determination; and none of the remaining 64 were considered “Overdue.”

The U.S. AbilityOne Commission’s (Commission) charge card programs for fiscal years (FY) 2020 and 2021, as required by the Government Charge Card Abuse Prevention Act of 2012 (Charge Card Act) conducted by RMA Associates, LLC (RMA), an independent public accountant firm.

To report internal control weaknesses, noncompliance issues, and unallowable costs identified in the single audit to the Social Security Administration (SSA) for resolution action.

In April 2021, the U.S. Postal Service announced that, due to declining mail volume, it would relocate or remove unnecessary letter and flat sorting equipment as appropriate from 18 selected facilities to make space for package processing.Our objective was to review the Postal Service’s plan to transfer processing operations from 18 mail processing facilities to analyze adherence to established policy and identify any associated risks and opportunities. For this audit, we obtained implementation plans, reviewed Postal Service handbooks, interviewed Postal Service managers, and performed site observations.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Finger Lakes Healthcare System, which includes two medical center campuses—Bath and Canandaigua—and multiple outpatient clinics in New York and Pennsylvania. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the inspection, system leaders had worked together for approximately three months. The OIG reviewed employee satisfaction survey results and concluded that averages from selected leadership questions were similar to or lower than VHA averages. Patient experience survey data showed that patients were generally satisfied with their outpatient care but less happy with their inpatient care than VHA patients nationally. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the OIG identified a vulnerability in staffing challenges at the Canandaigua VA Medical Center. System leaders were knowledgeable within their scope of responsibilities about selected VHA data used in Strategic Analytics for Improvement and Learning models, and should continue taking actions to sustain and improve performance.The OIG issued six recommendations for improvement in three areas:(1) Mental Health• Suicide safety plan training(2) Care Coordination• Patient transfer monitoring and evaluation• Advance directive sent to receiving facility• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training